The results demonstrate that a comprehensive small-group intervention employing motivational enhancement strategies can assist women in their efforts to reduce their risk of infection with HIV. Intervention participants increased their HIV-related knowledge, became more sensitized to their risk for infection with HIV, expressed intentions to avoid unsafe sexual practices, communicated their intentions with sexual partners, reduced substance use before sexual activities, and were less likely to engage in unprotected vaginal intercourse. These changes were observed following the intervention, and most were sustained during the three-month follow-up interval. The overall pattern of findings suggests that the motivational approach has considerable promise for HIV-risk-reduction.
This intervention integrated behavioral skills training with motivational enhancement. Supplementing the motivational enhancement approach with behavioral skills has not occurred in prior applications, primarily because such skills were often assumed to be present. Thus, it is often assumed that clients know “how” to change, but they do not know “why” they should. A second reason why skills training is typically not included is because such training can be highly prescriptive (i.e., offering specific directions, instructions, and assignments), a therapeutic style that is not compatible with the motivational approach (cf. Miller & Rollnick, 1991
). In the current intervention, we provided skills training in a manner consistent with motivational approaches. Thus, rather than prescribe specific strategies, we elicited possible change strategies from participants, facilitated behavioral rehearsal, and encouraged group feedback. Participants determined which risk-reduction goals were right for them, and which skills would allow them to achieve their goals.
Implementation of the motivational approach in a group context also represents a novel application. To protect the privacy of group participants, we provided feedback about risk status in individual reports and planned to discuss risk status and behaviors in a general way (i.e., less personally than is typically done in individual sessions). However, participants were willing to disclose risk appraisals, interpersonal relationship details, and safer sexual strategies with each other in a way that served to enhance the discussion. The group was also quite supportive of individual participants’ efforts at risk-reduction. We suspect that the group process provided additional motivational influences that facilitated individual change.
The design of the current study does not allow for direct comparisons between this combined intervention (viz., motivational enhancement and behavioral skills) and the skills-oriented interventions that have been investigated previously (e.g., DiClemente & Wingood, 1995
; Hobfoll et al., 1994
; Kalichman, Rompa, & Coley, 1996
; Kelly et al., 1994
). However, given the similarity of the populations studied, it is possible to obtain an indirect comparison by examining the effect sizes achieved in this and other studies.6
The mean effect size obtained in this study with a motivational approach (d
= 0.57, before correcting for inter-correlations among the dependent measures) exceeds those obtained previously with skills-based approaches in samples of urban women (see ), and compares very favorably to effect sizes obtained with skills-based HIV-risk reduction programs in a variety of populations (d
= 0.25; cf. Kalichman, Carey, & Johnson, 1996
). In addition, the effect sizes observed here compare favorably to those obtained in other health-behavior change contexts (d = 0.12; cf. Johnson, Carey, Kalichman, & Muellerleile, 1996
). The nature of these cross-study comparisons precludes strong inferences, and we do not mean to imply that motivational approaches are necessarily superior. However, the effect sizes obtained in this study clearly suggest that the motivational approach warrants further investigation with larger samples and advanced designs.
Although this study was not designed to provide a formal test of the Information-Motivation-Behavioral Skills (IMB) model (Fisher & Fisher, 1992
), the results are consistent with it. Together with results obtained recently with college students (Fisher et al., 1996
), these data indicate that the IMB model can be used heuristically to guide intervention development. Whether the IMB or other models best explain the results of this study will require further investigation. As leading theorists have recognized, the overlap among existing theoretical models is considerable (Fishbein et al., 1992).
Community-based research on high-risk sexual behavior creates challenges that must be recognized, including participant retention, measurement, and analysis of sexual risk behavior (cf. Ostrow & Kessler, 1993
). We implemented culturally sensitive recruitment strategies with an ethnically diverse research team, provided monetary incentives to defray the costs of participation, and held sessions in a convenient community-based facility. This careful attention to tracking and retention resulted in 74% of participants returning for the post-intervention assessment and 65% for the follow-up assessment. These retention rates are consistent with those obtained by other researchers (e.g., Kalichman, Rompa, & Coley, 1996
; Kelly et al., 1994
), and may constitute an upper limit of what can be expected with socially disenfranchised groups.
Assessment of risk behavior also poses challenges. Research has demonstrated that health education and assessment materials are often written at levels that exceed respondents’ reading abilities (Meade & Byrd, 1989
); low income adults tend to have the lowest functional literacy skills (Williams et al., 1995
). We were cognizant of these considerations when assembling our survey, but women still had difficulty completing it. Face-to-face interviews are not an attractive alternative, because respondents tend to report lower levels of socially sensitive behavior with this method (Catania et al., 1990
). Use of audiotaped (cf. Boekeloo et al., 1994
) or audio compact disc-administered sexual risk surveys warrants further study.
Assessment will remain difficult due to the frailty of memory. Catania et al. (1990)
have detailed reasons why respondents may be unable to recall sexual events. We purposely selected a two-week recall interval because it would be easy for participants to recall reliably (see Kauth et al., 1991
). Such a brief interval, however, provides few opportunities for sexual events to occur. A longer interval would have offered women additional opportunities to demonstrate their motivation and behavioral skills. Due to the brevity of the assessment interval, our results may underestimate the effectiveness of the intervention.
Finally, the distribution of sexual behavior tends to be inherently non-normal, creating problems for data analysis and interpretation. Development of improved measurement strategies, or more sensitive analytic strategies is needed. Biological outcomes (e.g., incidence of HIV infection) remains impractical due to low incidence, cost, and poor acceptance by participants (Coyle, Boruch, & Turner, 1991
). For the present, investigators can supplement sexual behavior measures with a network of measures, including HIV-related knowledge, behavioral intentions, and skills.
The limitations of this study deserve mention. First, not all women included in the sample were sexually active, reducing the sensitivity of our design. Future research might require that risk behaviors (e.g., an STD) have occurred during the prior 3 months. Second, we did not obtain a direct measure of behavioral skills. Use of role plays would provide a useful measure of the effectiveness of the behavioral skills training. Third, our design did not provide a control for the non-specific factors associated with any intervention. Research might compare the intervention evaluated here against other active interventions for HIV or other important social problems.
Future research might also compare the motivational approach with education or skills building only. Use of a dismantling design will permit inferences about the active ingredients of the intervention. The value of booster sessions, or the effectiveness of a briefer intervention would help to determine whether the intervention can be made more potent, and elucidate its limits. Given the urgency of the AIDS pandemic and the scant resources available for prevention, research exploring economical delivery modes (e.g., paraprofessionals) is warranted.